A Treatise on the Nature and Cure of Gout and Rheumatism, Including General Considerations on Morbid States of the Digestive Organs; Some Remarks on Regimen; and Practical Observations on Gravel

Among the very few medical authors who, like the Bard of the North or the Exile of the South, have realized the fable of Mid as, and converted paper into gold by the magic touch of their pens, Dr. Scudamore may, we think, be numbered. We do not speak of the direct transmutation, as it would be understood in Pater-Noster Rofr by the adepts in the trade. Far from it! Small indeed is the return of "shining ore," from those great granaries of literature, even although second and third editions roll majestically into them?-facilis descensus averni!?many an author, reputedly successful, could add with strict truth,?

* We have been accused of using language too figurative. But let it be remembered, that the Review of a work involves occasionally reflections, allusions, and digressions that are, in their nature, very different from what may be termed purely medical matter, and consequently require a different language and style to exjjress them with force and effect. Whenever the subject matter becomes grave and philosophical, the language, of course, should correspond, and derobe itself of all other ornament than correctness and perspicuity. We conceive, however, by the way, that the study of medical literature has suffered some retardation by the barbarous, uncouth, and slovenly language in which it has been too often the custom for medical authors to write. How disgusting this language appears to a youth who has just emerged from the study of Grecian and Roman lore, those who have any knowledge of classic elocution can say. We have seen numerous instances of that disgust continuing to operate till a period of life, when it was too late to retrieve the misfortune. But to return to the subject of this Note. We would be glad to know, by what rule we%are bound to adhere to the same precise and philosophical language, when describing the influence of the press on the progress of science, which we would use in describing the influence of a nerve on the motion of a muscle ? 1820.] Dr. Scudamore on Gout. 369 It maybe objected, that many works are published which escape without either censure or applause. But in this case, silence is the deadliest satire, since to excite animadversion itself is, in these times, some proof of merit.
We were going to say, that Dr. Scudamore was a fortunate author; but fortune or chance has not much to do in medical writings. Labor, improbus labor, is the grand engine; for although talent, like gout, is often hereditary, it is often also acquired, and the great apparent inequalities of ability in men, are in three cases out of four, dependent on unequal application. Animus hominis quicquid sibi imperat, obtinet. P. <Syr. Dr. Scudamore, however, has been fortunate in the choice of his subject. Gout is a rich subject; it is the offspring of wealth in the patient, anc} the parent of affluence in the practitioner; rivetting the one to his couch, and rolling the other in his chariot. No wonder then that so many volumes have been dedicated to this noble?nay, royal patron.
Dr. Scudamore is, we believe, the greatest writer on the disease under consideration, .that has appeared in this country. We do not mean an}' equivoque, in respect to the size of the book, but in regard to the labour and research employed in its construction. We cannot, however, but think that he has overdone the business in this third edition. The " obscurus fio" sometimes results from the <c brevis esse laboro"; but it much more frequently follows diffuse, laboured, and ultra-minute description. Besides, Dr. S. has now swelled the work to a price and size, that inevitably confine its circulation to the trunks, and exclude it from the ramifications of the profession. This is a great misfortune, and it is all owing to our author's over anxiety to leave nothing unsaid of undescribed on the subject. A single passage from Dr. Scudamore's symptomatology wjll elucidate this remark.
Thus some pages are taken up in describing the kinds of pain, and the metaphorical expressions which patients use under the tortures of gout. " Observation has taught me, that the sense of weight and total loss of power, are most severely felt, when the whole of the anterior part of the foot is the seat of disease ; that inflammation in the Jirst joint of the great toe produces the strongest throbbing; and that the sense of tightness is most urgent when the elbow joint, and the tendons at the wrist are the parts affected." 32. Now we would ask Dr. Scudamore the cui bono of the information, that stronger throbbing attends inflammation pf the jirst than of the second joint of the great toe? This 370 Analytical Reviews. [Jan.
In short, we hesitate not to say, and Dr. Scudamore will, we think, ultimately acknowledge the truth of the assertion, that the work under review, like the Roman Empire of old, has lost in strength what it has gained in expansion, and that were he, in a future edition, (and man}' editions will be demanded) to reduce its dimensions one half, he would increase its utility tenfold.
In the following Analytical Review, it will be necessary to pass over much of what may be termed elementary matter; which, though proper in a professed Treatise on Gout, would be totally misplaced in a Journal of Medicine.
In the arrangement, we think that Dr. Scudamore has greatly improved upon Cullen; and in the history and symptomatology of the disease we have no fault to find, as we before hinted, but that of prolixity.
In respect to the Etiology of Gout, Dr. S. has somewhat altered his sentiments of late, on the hereditary nature of the disease. He now attaches more importance to hereditary predisposition than formerly. The beautiful passage in Sydenham is well known, where he reflects that gout " destroys more rich than poor persons, more wise men than fools; which seems to demonstrate the justice and strict impartiality of Providence, who abundantly supplies those that want some of the conveniences of life with other advantages, and tempers its profusion to others with equal mixture of evil." In the following commentary of Dr. Scudamore on this passage, we cordially agree with its enlightened author. " Since the period at which these sentiments were entertained, luxury has so much increased among the whole community, that the gout sometimes finds entrance even into humble dwellings. In ( London, amongst the inferior classes, I have observed butchers, innkeepers, butlers, and porters in wealthy families, to be very subject to gout. It is also frequent among coachmen, chiefly such 1820.] Dr. Scudamore on Govt. 571 as live in femilies; for, together with much excitement fronji liquors, they are constantly exposed to the variations of the weather. In short, such stations and occupations as most induce repletion and inactivity, or full living, with only passive exercise, lead to gout; and even in some constitutions, in which there is great tendency to plethora and corpulency, moderate indulgence in diet, notwithstanding active exercise, seems to implant the disposition to the disease." 6*7.
On the predispositions resulting from mental disquietudes, severe study, animal food, strong liquors, indolence, plethora, nimia Venus, and climatorial influence, Dr. Scudamore's remarks are just, but without any thing particularly novel. The section on " a morbid state of the digestive organs, considered both in its particular relation to gout, and in a general view," contains a great deal of excellent matter, and on this section we shall dwell for a few minutes. Dr. S. truly observes, that " the over-excitement of the stomach and chylopoietic functions must lead to relative derangement and debility;" and it is in this, he thinks, that the acquired, in contra-distinction to hereditary * predisposition, principally consists. irregular; the faeces unnatural in colour and smell. " Sometimes they are passed as pellets; and when more formed by the bowel, it occurs, not unfrequently, that they are so contracted in size as to convey the apprehension of some stricture of the canal; but the effect appears to be really owing to the unhealthy state of secretions, and to muscular contractions" of the bowel irregularly occuring from irritation. It sometimes happens that air is formed so abundantly in the intestines, either from undigested aliment, or possibly from actual secretion, or both, that its effects in producing painful distension, alone serve to cause a most distressing state of complaint. The discharges are commonly not formed, but are remarkably tenacious. They assume the appearance of pitchy blackness, or are muddy, or resemble dirty clay; and when the complaint has been of long continuance, an excessive quantity of. mucus is secreted in the intestines, which incorporates itself with the fasces, and sometimes exhibits almost the appearance of purulent discharge.* This mucus is to be distinguished from the gelatin-like appearance, which is seen occasionally in the evacuations, when the bowel suffers excessive irritation from an acrid purgative, or when under dysenteric affection ; in which case, it appears detached from the faeculent matter, apparently almost organized from its firm consistence, and is, indeed, altogether different from the slimy accumulation before mentioned. 1820.3 _ Dr. Scudamore on Gout.

373
This habitual mucous secretion has always appeared to me an indication, that the morbid condition of the alimentary canal has been of long standing. In the same manner we see the urine loaded with mucus, when the bladder is diseased, or under permanent irritation from a morbid condition of its contents." 83.
We have not room for any farther notice of this Section in our author's work, but recommend it to the careful study of our brethren.
It is well known that Dr. Scudamore has directed his attention much to the function of the kidnies, as constituting a very important link in the pathplogy of the digestive organs. When gout is in question, the patient frequently experiences a deficient secretion of urine a short time before the occurrence of the paroxysm, the fluid itself being of a deeper colour than natural. In people of a very nervous temperament, however, the urine is sometimes passed copiously, and of a pale colour. In the paroxysm, Dr. S. has found the morbid urine much increased in specific gravity, as ranging from 1.010 to 1.015, and sometimes even to 1.035, possessing the natural acid character, invariably, when in the recent state; but, from its high degree of animalization, soon becoming putrid and alkaline. The pink dust and mucous sediments in urine, are inseparable companions of gout: '" The appearance of these sediments is entirely dependant on a faulty state of the digestive organs; and upon unhealthy assimilation." 98.
Among the exciting causes of gout; Dr. S. enumerates the heating and injurious qualities of Champaign.
" If it has power to excite a first fit, we need not wonder that it is a fruitful occasional cause, in producing the returns of the diseasfe." , " Cold, with or without wet, applied to the body generally, or to the lower extremities only, especially when in concurrence with fatigue, proves, in an equal degree, exciting to the gout, in an individual who is predisposed to the disease, as to the phlegmasia^ in general; and it is by far the most frequent of the exciting causes. ' Cold, whether applied locally or generally, acts most powerfully when conjoined with wet; but certainly the.Easf wind, by itself, is a severe and active agent." 108.
Under the head?" Proximate Cause," Dr. S. has discussed, and, as is usual on such occasions, subverted all preceding theories, in order to make way for his own. This, however, he has modestly brought forward under the title of " Ratio Symptomatum, or the theorytof the symptoms, including the chemical history of the urinous sedi- meats." In the following extract, the prominent features of our author's theory of gout will be seen.

1820.]
Dr. Seudamore on Gout. 375 vena portarura, and the consequent functions of the liver; together, with the production of a morbid change in the secreted products of the alimentary canal in general, and of the kidnies in particular." 141-42. Although we suspect that this theory leaves us but little wiser than before; yet, as it tends towards a rational mode of treatment, and appears to grow out of the facts and actual phenomena of the disease, at least as naturally as most of its predecessors, we shall not enter into any captious examination of its defects or weak points, in this place, though we shall make a few observations on its comparative merits presently. We shall pass over the Sections on Diagnosis and Prognosis, in order to concentrate the more our attention on the final object of all our investigations?the Treatment. The prohibition against therapeutical interference in the paroxysm of gout, by such a man as Sydenham, who was himself a martyr to the disease, and who studied all its phenomena with the most profound attention, has long and deservedly, we think, exerted a powerful influence on medical practice. " It is obvious (says Dr. Seudamore) that he derived all his opinions from the doctrines of th^ humoral pathology." This is not quite so obvious to us. We donot see any reason why the clear and comprehensive mind of Sydenham should not found some of its opinions Gpon the observation of facts, as well as the mind of Dr. Seudamore.
Dr. S. brings forward the following passage, apparently to expose the theoretical errors of Sydenham. " In this disease, Nature seems to have the prerogative to expel the peccant matter, according to its own method, and throw it off from the joints, there to be carried off by insensible perspiration." 173. Now, if the reader will please to revert back to the passages just extracted from Dr. Seudamore himself, he will find a mere amplification of the above doctrine of Sydenham, not exactly totidem verbis, but certainly conveying a similar import. Dr. Seudamore, indeed, has somewhat afored the route of the peccant matter, and speculated on its cheinieal nature; but still it is unhealthy, w unassimilated matter;" and the " blood-vessels are surcharged with blood, unhealthy in quantity, and probably also in quality," with " excess of saline ingredients in the urine and to crown the whole, Dr. S. is forced to acknowledge that this " increased excretion of other animal principles" is not only a sign, of disease, but " a salutary process which Nature is performing to relieve an overloaded and faulty state 376 Analytical Reviews. [Jan.
of the circulation of the liver, and the organs associated in its functions." What, in the name of common sense, is all this but a new version of the old and ridiculed humoral pathology of Sydenham and his predecessors? Let us not then be teazed with the declamations of the moderns against the humoral doctrines of the ancients, while the former can only coin new phrases for the ideas of the latter.
Dr. Scudamore, in his commentary on the above passage of Sydenham, while he acknowledges " that nature is seeking a remedy for herself in a fit of the gout," and that her powers are generally sufficient in slight and primary attacks, yet draws a frightful picture of the ultimate effects of the disease when left to itself. But we may just hint here, that one reason why we see fewer cripples from gout now-a-days, when the work is taken from the hands of Nature, and the medicina perturbatrix is in full play, may be the erasure, from the list, by sudden deaths, apoplexies, cardiac aneurisms, 8tc. c>f a considerable number annually, before the sequelae, delineated by our author and others, could becomp apparent. But while we deprecate strong measures of cure during the paroxysm of gout, we advocate the most energetic means of preventing the necessity for this painful, though salutary effort of Nature. In the following passage, there is a saving clause following the word " unless," which enables Dr. Scudamore to accommodate all parties.
" I would assume it, therefore, as a principle, that we should attempt the prevention of a fit of gout, if warned of its approach ; and interrupt its progress when formed, unless such a state of the constitution exist, that the gout has taken the place of another more serious disease; or may be expected to prevent one which is threatening, and more to be dreaded than itself; but eyen in this case, it is incumbent upon us to moderate the violence of symptoms; to study and fulfil particular indications; and carefully to estimate the balance of the present evil with the expected good." 175.
Now the question is whether we may not, by interrupting the progress of the fit when formed, always endanger the supervention of son)e other form of the complaint, or its conversion into some other disease. This we firmly believe ; and the sanction of a Parry, who studied in the very head quarters of gout, and drew his conclusions from a wider field of experience than any author now living, is 3, sufficient shield for our creed. But we shall now hasten to lay before our readers a comprehensive analysis of Dr. bcudamore's Therapeutics. congestion of the vessels of the head, liver, or other internal organ be indicated, without corresponding increase in the pulse, then local detractions of blood. We believe that no rational practitioner, of the present day, would withhold these means, under the same indications, whether there was or was not gout in the system.
When there is a tendency towards hsemorrhoidal discharge, it should be promoted, by aloetic and saline purgatives. The costiveness, so usual a forerunner of gout, should be removed by active purgation with calomel, antiipony, and ex. colocynth.
" If a furred state of tongue, with heart-burn, nausea alternating with a craving appetite, and acid eructations be present, an emetic of ipecacuan should be administered." P. ) 77.
If the threatening symptoms continue, the means recommended hereafter for the paroxysm itself should be put in force ; and if, after the employment of suitable evacuations, the internal secretions remain in a vitiated state as indicated by the faeces and urine, u small unirritating doses of mercury at proper intervals," with a gentle aperient once a-day occasionally conjoined with a stomachic hitter, \vill be found useful. To these means must be added a regulated diet, or even abstinence; exercise; repose of mind; early hours; in short, a change of the laedbntia for the juvantia.
II. Treatment of the Paroxysm. Blood-letting is not so allowable in this as in other phlegmasia}; since? " It usually happens in gout that the increased excitement affects the nervous system much more than the heart and arteries; and, as I have before stated, the redundancy of blood appears to belong rather to tlje circulation of the vena portarum, than to that of the general system. It may also be assumed as a practical fact, that this kind of partial plethora is more favourably and effectually removed by purgatives and diuretic medicine than by the detraction of blood itself." P. 179* General blood-letting, indeed, Dr. S. considers wholly unnecessary, and quite ineffectual in the removal of the local inflammatory action. Nevertheless, when the general excitement is strongly marked, general bleeding will be indicated?and a fortiori, if an internal organ be inflamed, S78 Analytical Reviews. [Jan.
for then the gout must be totally disregarded. It is obvious that the above precepts are entirely applicable to all the phlegmasia;, and bear little, after all, on the particular treatment, if indeed there be any particular treatment required in gout. Local congestions or inflammations in gout, as in all other cases, are to be met by local abstractions of blood.
III. Emetics. From our author's own experience, he does not advise the employment of emetics?" unless an evacuation of the stomach in a full degree is obviously required, from its being pointed out by indications of irritating contents." 182. This is one of those sound but very common truths, to which no man can possibly refuse his assent.
IV. Cathartics and Diuretics. On these Dr. S. chiefly relies for the successful treatment of the paroxysm. " Occasional doses of calomel, in conjunction with antimonial powder, compound extract of colocynth, and a little soap, fulfil, in the most useful manner, the first part of the intention (purgation) which I have expressed; and they should be repeated each night, or each other night, according to the degree of vitiation ?which the bilious and other matters from the bowels appear to possess; and according to the advantage derived." 185.
In co-operation with the above, our author has experienced " the most remarkable success from a draught composed of magnes.gr. xv. ad xx.; magnes. sulph. 3!. ad 3ii.; aceti colchici 3i. ad 3ii; with any distilled water the most agreeable, sweetened with any pleasant syrup, or with xv. or xx. grs. of ex. glycyrrhizse." When much feverish heat of skin has prevailed, he adds twenty or thirty grains of potass, carb. accurately neutralized with lemon acid. In this latter case he prefers the carbonate of magnesia to th?e calcined, using a larger proportion. This draught should be repeated at intervals of four, six, or eight hours, according to the freedom of its operation, and the urgency of the symptoms; the purgative and diuretic medicines being actively administered, "until the gouty inflammation subsides, and so long as the urine, ?which is first passed in the morning, retains a high specific gravity, or deposits sediment." J 87.
V. Mercurials are only given as purgatives and alteratives, as stated in the preceeding section, but never to excite mercurial action in the system.

1820.]
-Dr. Scudamore on Gout. ? 379 VI. Pretended Specifics. It is sufficient to say that our author very properly and very ably exposes and condemns the whole list of pretended specifics in gout, from the Eau Medicinale of Husson down to the vinum solchici of Home.
With the effects of elaterium and opium, T am the least acquainted ; but I have had abundant opportunity to know that each of the other medicines, sooner or later, disappoints the patient of his expected cure, rendering merely a palliative assistance, and keeping the disease dormant for a time only, so that it is left to prey on the constitution with more lasting and serious ill effects." Page 198.
The following observation of Dr. Sutton, on this remedy, is worthy of attention. " In the use of this medicine, also, it.must be observed, that t&a benefit is not connected with a small dose of opium; but the quantity is defined by its producing a complete cessation of pain." Tracts.
" I have myself found the use of this medicine remarkably successful in its crude state, and when joined with a small dose of antimonial (in preference James's) powder. The patient being furnished with twelve pills, each containing one grain of crude opium and half a grain of James's powder, may be desired to take one, two, or, if pain be very severe, even three at bed-time, as the first dose, and repeat one every hour or two afterwards, according to the degree of pain; this being the only regulation as to the quantity to be employed, when no contra-indications are present." 224.
Dr. Scudamore informs us that he has had many opportunities of ascertaining that the Lancastrian, or blackdrop, agrees with many individuals much better than the common preparation of opium, disturbing less the stomach, during its immediate operation, and the head on the following day. Our author also speaks in favourable terms of Mr. Battley's liquor opii sedativus, as producing less inconvenience to the nervous system than other preparations of opium. He recommends it in doses similar to those of the tinct. opii of the Pharmacopeia. " The pulvis ipecacuanhae comp. is also an excellent form of opiate ; and when joined with the use of saline medicine, sometimes proves more useful than any other preparation." The other narcotics are inferior in virtue to opium ; but may be occasionally useful as adjuvants, where idiosyncrasy forbids the latter. Stramonium in such cases is the best succedaneum that our author has found for opium.
On the dietetic and moral management of the patient, during the paroxysm, Dr. Scudamore's remarks are judicious, but in unison with general experience. We shall therefore pass on to an important topic. [Jaft.
Local Treatment in the Paroxysm, ft is on this point, we believe, that modern improvement is conspicuous; chiefly by steering a middle course between the flannel of Ciillen, and the cold of Kinglake. " The inflammation of gout, (says our author,) has never been treated upon fixed and regular principles. It has most commonly been left to its own injurious' course, unchecked and unrelieved."

241.
Upon this we would remark, that each author considered liis principles as fixed and regular as Dr. Scudamore's; and it would be too much to expect, that the latter system, alone shall stand, like a rock of adamant, and defy the waves of Time.
Leeches. Local bleeding, however performed in gout, Dr. S. looks upon as not only unnecessary, but " in most instances injurious." We consider this to be by no means authorized by the evidence of facts. A host of authors have not only sanctioned but recommended the measure; and notwithstanding the constitutional nature of gout, we believe that the violence of its local manifestation may often be safely and efficaciously moderated by leeche9, especially in primary attacks, and where neither the constitution is broken down, nor the texture of the parts much deranged by repeated paroxysms.
Dr. James Clark, of Rome, on his way to this country a few months ago, directed his attention, at the Val de Grace Hospital in Paris, where M. Broussais presides, to this subject; and his notes, which we have had the advantage of perusing, bear ample testimony to the beneficial effects of local bleeding by leeches in the inflammation of gout. Indeed, the distinguished physician abovementioned, uses scarcely any other local treatment itvthis complaint, either in the vast establishment over which he presides, or in private practice.

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The general excitement, in this case, grows confessedly out of the local, as its cause; and yet, Dr. Scudamore's -principle would direct us rather to obviating the effect, than to removing the cause on which it depends. When local inflammation has kindled up general fever, we are by no means to direct our attention exclusively, or even in preference, to the latter. Our local depletion should then be equally active, or indeed more so than before ; the general depletion being put in force, merely as an auxiliary to counteract the constitutional effects, while topical depletion is to be vigorously pursued to remove the cause of all. We appeal to every man of experience and observation, for a judgment on this point of discrepancy between our author and ourselves.
Of vesieatories and irritants in acute gout, Dr. S. cannot speak from experience; and, indeed, they require no notice. We were somewhat surprised to find a page of Dr. Scudamore's Practical Treatise taken up with Lucian's Tragopodagra, copied from Guilbert, and which has been wisely omitted in Dr. Johnson's last translation of that able work. * Warmth is condemned by Dr. Scudamore, as belonging to the " worst part of the ancient practice." And yet his own " tepid evaporating lotion," might, without much, difficulty, be proved to be a branch from the same stem. Hot bathing of the extremities in acute inflammation of gout, no one would surely advice. " When the cleanliness and softening of the skin of the surrounding parts, together with that immediately affected, are desired during the paroxysm, the use of free sponging with tepid water is much to be preferred." 247.
Poultices. Although our author considers that a free employment of relaxing poultices, " made in the ordinary way," has the disadvantage of increasing cedematous swelling, and subsequent debility ; yet, " he has found great cause of satisfaction in the occasional use of a poultice, made with bread which has been scalded with boiling water, pressed through a strairier to dryness, and again rendered of sufficiently soft consistence by means of the lotion which shall presently be described. It is then to be applied, thick in quantity, very moist, just tepid, and without any intermediate covering between it and the part affected." When the hands or feet only, are the seat of complaint, Dr. S. uses these poultices only at night. poultice to be very much more useful than the lotiou applied by compresses; and have directed it to be repeated twice or thrice in the twenty four hours, according to circumstances." 250. For a short time after the discontinuance of (he poultice, the part should be covered with a single layer of flannel.
Dr. S. has given the form of Pradrer's cataplasm, as translated by Dr. Johnson from Guilbert's work, and thinks that, with the omission of some bf the ingredients^ it deserves trial in obstinate cases of chronic gout.
Other Modes of Evaporation. Dr. Kinglake's revival of cold in gouty inflammation is wisely condemned by our author, who observes, that " from all he can learn of the practice of applying cold water, the relief is never so certain as the danger" c2o2. The following is Dr. Scudamore's favourite topical application in gout; the local treatment being, however, in his opinion, of secondary importance, though still a point of great magnitude. " I have now the satisfaction to state, that in about one hundred and thirty cases, I have made very free use, and with the best success, of a lotion composed of one part of alcohol, and three parts of mistura camphorae ; applying it to the affected part by means of linen rags, first rendered just agreeably lukewarm by the addition of a sufficient quantity of boiling, or very hot water.
In this manner, a prompt convenient method is afforded of using the lotion, on the principles on which I recommend its adoption. The rapidity with which the alcohol alone would evaporate, is advantageously retrained by the dilution with the camphor mixture ; and the warming it, by the addition of hot water* preserves it from that escape of the volatile parts, which the sudden heat of the fire would occasion. In using the lotion, if it be applied either hot or cold, the intention of the remedy is considerably frustrated; and I have observed, that from being made too warm, its operation has been injurious, rather than beneficial. If the temperature be measured by the thermometer, I may state that it ought not to be less than 75 degrees, nor more than 85 degrees. I consider, however, that the expression of just agreeably lukewarm, is a secure and sufficient direction to the patient. The linen compress, constantly kept wetted with the lotion, should consist of six or eight distinct folds, one laid upon another; and the slightest and coolest covering only should be used in addition. The effects of this lotion, when it has Been attentively employed, have been most satisfactory, and have really answered my warmest expectations." 253.
Dr. S. asserts, that he has not, in any one instance, seen the least tendency in this lotion to produce retrocession of 1820.] Dr. Scudamore on Gout. 383 the artliritic inflammation, and that in only three solitary cases had it-been " laid aside from disapprobation." The odour, of the lotion is pleasant and refreshing; but the Jinen compresses should never be allowed to become dry ; one set being alternated with another, when the part is much heated, for the advantage of a cooler medium of application. When the gouty inflammation is nearly overcome, or when it happens that the lotion, applied by coinpresses, ceases to produce comfortable sensations, and, on the contrary, occasions chilliness or numbness, the method is to be changed, and " the parts should be sponged with the lotion frequently, and left damp, with or without subsequent covering of a light kind, as circumstances may direct." Q5ti.
The good effects of this evaporating lotion, however, are chiefly discoverable when the inflammation is seated in the more superficial tissues and structures; in proportion as the disease is remote from the surface, its operation will prove less efficacious, and in opium (the proper indications being fufilled) our superior confidence must be placed. In these latter cases, our author employs, in pre-Analytical Reviezos. [Jan.
the great majority of cases under his own manageraen , bitters, and tonic medicines, of every description, have been unnecessary; on the other hand, he has preferred a mild course of aperients and alteratives, in conjunction with a regulated diet and general regimen. Where simple debility, however, succeeded a long, and exhausting effort of Nature, or an improper interference of Art, he has used, with advantage, the following combination : R. Calumbee radicis concisi gj ad ill. Cascarillae corticis contusi 5ij ad ffi. Rliei radicis contusi iJj ad 9ij. The ammoniated tincture of iron, where no tendency towards inflammatory plethora exists, may be usefully employed. Another form of tonic stomachic medicine, which our author has found to agree well with gouty and dyspeptic sto'machs is, " the union of decoct, aloes, compos, infus. gent, compos, et mist, camphora;, with a moderate addition of spir. ammon. compos, to be given once, twice, or thrice in the day.
As an alterative pill, to be given with the view of exciting healthy secretion, Dr. S. recommends five grains, every second night, of the pil. hydrarg. sub. compos, as preferable to the pil. hydrargyri. For the local sequela; of gout occasioning lameness, with oedema, coldness of skin,^ inability to bear the weight of the body, with a shrunk condition of the muscular fibre, Dr. S. recommends, in addition to the morning sponging and subsequent friction, the application of the following liniment: Tinct. lyttae 5$ liniment, camp. comp. liniment, sapon, compos, aa 5ifi. M.
The foregoing didactic precepts relative to acute gout, are illustrated by a series of cases occupying sixty pages of closely printed letter press; and this is one of the items by which our author has, we think, very injudiciously swelled the work to a size and shape so unwieldy, as to cripple its circulation completely.
Chronic Gout. This form of the disease is characterize^ by our author in the following definition : " Inflammation and pain more slight, irregular and wandering, than in the acute; faint redness of surface; much permanent dis-? 1820.] Dr. Scudamore on Gout. 385 tension of parts, or continued oedema, and impaired moving power, without critical indications of its terminating; commonly associated with a morbid state of the digestive organs, a languid or oppressed circulation, and much nervous irritation in the system." 14.
Although chronic is most commonly an ultimate consequence of acute gout, yet' it sometimes occurs in subjects who have never experienced the acute form. A great variety of anomalous constitutional indispositions attend it, particularly of the dyspeptic class, with fugitive cramps and spasms in various parts of the body, which are very distressing to the patient. 386 Analytical Reviews. [Jan.
roneouslv, termed " rheumatic gout/' which would have puzzled Dr. Scudamore himself to draw the line of de*marcation between the contending diseases. " Nevertheless (says Guilbert) we every day meet with examples of gout and of rheumatism, resulting from a combination of those causes; and so, in truth, do we see rheumatic gout, as well as gouty rheumatism, mixed affections, whose characters partake of both diseases, and whose treatment requires correspondent modification." Treatment of Chronic Gout. In acute diseases, as Dr. Scudamore well observes, the bold hand of the Empiric, or some happy effort of Nature, may sometimes be speedily successful ; but when the chronic form of disease is deeply established in the system, no pretended universal, or even expeditious method of cure, can have any just claim to our regard. Our author, in this place, draws our attention to three modifications of chronic gout, which he thinks are necessary to be discriminated from each other, for the sake of a more successful treatment. The principal features of these modifications, with the appropriate methodus medendi, as laid down by our author, we shall endeavour to present to the reader.
I. In the nervous temperament, where the arthritic diathesis may be strong, yet the powers of the system unequal to the production of regular gout, the internal functions will be found weak and irregular, with much morbid nervous sympathy. Here, although a comparatively too full diet may produce slight inflammatory actions, with pain, swelling, and difficult motion of parts, yet general bleeding will seldom, our author thinks, be necessary. " The employment of a purgative diuretic medicine in the saline combination, such as before recommended, with the occasional interposition of a dose of hydr. submur. et pulv. jacobi, and the abstraction of all heating stimuli, will usually constitute a treatment of sufficient activity i" 346.
Pain and nervous irritation must be soothed by gentle anodynes at bed-time; and, in such cases, Dr. S. recommends stramonium and lactucarium, or the latter in combination with small doses of the pulv. ipecac, compos.; these, he thinks, are preferable to opium and hyoscyamus.
" The local treatment is to be conducted exactly on the principles formerly described." 346'.
Inflammatory tenderness being removed, friction and bandages will be eminently useful. In respect to the more permanent measures, the internal functions, more especial- 1?20.] Dr. Scudamore on Gout. 387 ly those of the liver, kidnies, and digestive organs, must be watched carefully, and steadily improved, both by regimen and remedies. ,In the summer season, the use of the warm sea bath twice or thrice a week, will form a valuable auxiliary* II. " The consequence of acute gout, when its repeated invasions have impaired the energy of the constitution; and from the weakened circulation which is induced, the chronic diseased action alone takgs place. The functions of the internal viscera are more or less deranged; and the"nervous system is much disturbed.
" In this example, we commonly see that the primary character of constitution remains to so great a degree, that signs of plethora are often manifested; and slight local inflammation is readily aggravated by the injudicious use of stimulants. Under these circumstances of vascular susceptibility, in conjunction with languid powers, the treatment which has been stated in the preceding example is generally applicable. The alterative aperient plan will, however, sometimes be required to a greater extent, and for a longer continuance. The state of the secretions will be the true guide to the practice which should be adopted." 348.
In certain states of debility and general disorder into which some gouty invalids decline, or in anomalous cases of disease, where gout is suspected in the system, without having made any local demonstration, it has been usual to invite a fit of the gout " by various modes of stimulating treatment." This our author thinks a hazardous practice, and so do we; but, in such cases, we certainly should be for encouraging the local disease by mild means, while we still agree with our author, that the essential treatment must " consist in a regular and persevering attention to the chylopoietic functions, both by means of medicine and regimen." In respect to Bath waters, Dr. Parry informed our author, that in no form whatever were they beneficial during the paroxysm, or in any inflammatory disposition in the intervals. In that dyspepsia, however, which is joined with a languid circulation and want of nervous energy, but without any inflammatory tendency in the organic system, " these waters appear calculated to be eminently useful." " In most instances, and indeed almost without exception, the waters of Cheltenham prove highly beneficial to gouty persons ; and particularly when joined with a medicinal alterative and regulated regimen. The water, No. 4, is that which is most suited to ,th$ gouty patient; and especially in the first instance."?" The wafers of Leamington are entitled to similar praise with those of Cheltenham, but their aperient effect is less active." '388 4 Analytical Reviews. [Jan.
III. This is the chronic state of gout arising out of repeated acute attacks, with local changes of structure, irritable nervous system, but healthy condition of the natural' functions.
" With this form of chronic weakness, rheumatism is often, blended, and the patient is extremely susceptible to every vicissitude of weather, and especially to wet, and damp cold air," " In the pains and frequent threatenings of inflammation, which, under these circumstances, continually occur, the combination of a narcotic and a sudorific appears particularly useful; and for this purpose, the compound powder of ipecacuanha, in small doses, twice or thrice in the twenty-four hours, often proves a valuable medicine, strict attention being at the same time paid to the proper action of the bowels and kidnies. In this form of the complaint, however, I must not lose sight of the recommendation which is due to the combination of stramonium and lactucarium, from which I have repeatedly seen the best effects derived." 3()2.
It is in these cases that our author has seen much benefit result from a system of tepid bathing, especially in the Buxton waters, with friction. This section of our author's work is illustrated by between fifty and s^xty pages of cases, which we shall, of course, entirely pass over. We cannot but lament this supererogation. We conceive that one-fourth of the space would have been quite sufficient for illustrations of this kind, after the minute detail of principles and indications previously laid down.
We now come to the last division of the subject; namelv.
y 9 Retrocedent Gout. This, our author thinks, is of rare occurrence, excepting from mismanagement or walit of care.
The transference is most apt to attack the stomach or intestines, or both in successiorf. In the former it produces exquisite pain, spasm, and sickness; in the intestines, enteritis, in its worst form, too frequently results. In either case the danger is pressing; and if relief be not obtained, death soon closes the scene. If the translation be to the brain, in its worst form, apoplexy is produced, and is generally fatal.
" Sometimes (says Dr? Cullen) the internal part is the heart, which gives occasion to syncope; sometimes it is the lungs, which are affected with asthma." Dr. Scudamore has never seen any instances of translation to these latter organs. But others have seen numer-1820.] Dr. Sctidamore on Gout. 389 ous examples of such.* It is not, however, in sudden translations, during a paroxysm of gout, that we are to look for the lesions of internal organs from that source, but to the slow conversions of external gout into chronic inflammations and irritations of internal structures. This wide and important field Dr. Seudamore has left almost without cultivation, while the volume has been swelled beyond all bounds, by minute, and, in many instances, unnecessary details of common and open forms of the disease.
Causes of Retrocedent Gout. The most frequent are vicissitudes of temperature applied to the body generally, or cold to the affected parts. Here Dr. ^Seudamore relates several interesting instances illustrative of this cause. " When cold is the hurtful agent, the internal symptoms which are produced are probably, for the most part, of an inflammatory uature.
I have formed this opinion from such cases as have come under my own observation; and from the general information which I have collected." 434.
Gout is often rendered retrocedent by the agency of certain stimuli suspending the external gouty action, as, for instance, in the use of Eau Medicinale, &c. Indigestible food, violent passions of the mind, and other accidents, have also considerable power in interrupting the regular process of gout, and transferring it to a predisposed internal organ or tissue.
Diagnosis. To distinguish between spasm and inflammation, in retroceded gout, is often a task of no small difficulty. " In an attack purely spasmodic, the rigidly contracted state of the abdominal muscles, and the relief which is afforded by strong pressure, are very distinctive.
When it is purely inflammatory, the tender state of parts to the slightest weight or pressure; the more regular diffusion, yet greater fixedness of the pain; the sympathetic fever which is instantly produced; and, indeed, the very physiognomy of the patient in the comparative situations of attack, will, to the experienced practitioner, be a description of the nature of the disease. The state of the pulse, as whether small and indistinct, or fujl and oppressed, or in vigorous action in any way, will materially direct the judgment; and the state of the skin and features, whether cold and collapsed, or in contrary states, is a guidance of importance. Dr. Cullen, and authors in general, appear to have considered it as a settled axiom of practical doc-. # See a remarkable case related by Guilbert, page 23 of Dr, Johnson's [Jan.
trine, that debility and spasm, and not inflammatory action, seize1 the internal organ in the case of retrocedent gout. " A perfect conviction prevails in my mind, that, in a genuine example of retrocedent gout to an internal organ, inflammatory action is the more common occurrence, and that spasm alone is comparatively rare. The mixed action of spasm and inflammation may however, be expected to happen still the most." 436.
Treatment. In every case of retroceded gout Dr. Culleti directed a stimulating treatment, and this is still the popular custom in this country. Every gouty invalid has his bottle of Cogniac, Madeira, or Usquebaugh, safely deposited for immediate use, when the enemy attacks the stomach.
When the retrocession consists purely of spasm, it is all very well. But when inflammation exists, the practice is extremely questionable, if not entirely objectionable. The life of our patient hangs on the discrimination which we exert.